Identifying Data:

Age: 60 years old

Sex: Male

Date & Time of encounter: May 6th, 2022

Location: Woodhull Medical Center

Race: Black

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

 

Chief Complaint: Leg pain x 10 days

 

History of Present Illness:

Pt is a 60 y/o male smoker with Hx of polysubstance abuse, HCV, who presents to the ED complaining of 10 days of worsening left lower leg pain, which is now constant, 10/10 severity, located mostly in the calf region (does not radiate anywhere else), and of “pressure” and “burning” quality. The pain is worse with palpation and walking, with no alleviating factors. He also complains of associated swelling and redness of the area. The patient reports injecting heroin into the same left calf area about 2 weeks ago. He states he did not seek medical help earlier because he thought the pain would resolve on its own. Otherwise, no other trauma/injury. He denies fever, chills, SOB, chest pain, palpitations, numbness, or cough. 

 

Past Medical History:

Polysubstance abuse (cocaine, heroin)

Hepatitis C

Depression

Immunizations – unknown 

 

Past Surgical History:
Denies past surgical history.

 

Medications:  

No medications on file. 

 

Allergies:

Denies any known drug, environmental, or food allergies.

 

Family History:

Noncontributory. 

 

Social History:

Habits – (+)cigarette smoker. (+)illicit drug use. (+)drinks alcohol occasionally (reports on occasion).

Sleep – No complaints

Travel – No recent travel. 

Residence – patient is currently living at a local shelter

 

Review of Systems:

General – Denies recent fever, chills.

Skin/nails – (+)redness. 

Head – Denies headache, dizziness, lightheadedness, recent head trauma.

Eyes – Denies visual disturbances. 

Ears –Denies change in hearing. No hearing aid use. 

Nose – Denies congestion, rhinorrhea. 

Mouth/throat – Denies sore throat, difficulty swallowing. 

Neck – Denies pain, stiffness, injury/trauma. 

Pulmonary – Denies SOB, DOE, cough, wheezing, cyanosis, hemoptysis.

Cardiovascular – Denies chest pain, palpitations, syncope. 

GI – Denies abdominal pain, nausea, vomiting, diarrhea, constipation, excessive belching, rectal bleeding. 

Genitourinary – Denies dark urine, incontinence, urgency, dysuria, hematuria, frequency.

Nervous – (+)gait change (difficulty bearing weight on LLE due to pain). Denies tingling, weakness, numbness. 

Musculoskeletal – (+)leg pain. (+)leg swelling. Denies body aches, back pain, joint pain. 

Hematologic – Denies history of DVT/PE. 

Psychiatric – (+)depression (unchanged from baseline). Denies suicidal thoughts or hallucinations. 

 

Physical Exam: 

Vital signs: BP: Seated L-arm: 128/75

                  RR: 16 breaths/min, unlabored

                  Pulse: 73 bpm, regular

                  T: 97.3 degrees F (oral)

                  O2 Sat: 99% on room air 

                  Height: 5 ft  8 in Weight: 150 lbs.       BMI: 22.8

 

General: (+)acute distress, appears to be in pain. Pt alert, oriented. Well nourished. Looks stated age. 

Skin: (+)skin to left calf region is hot to touch, erythematous. Otherwise, skin is warm. No ecchymosis. Nonicteric, no other lesions noted, no tattoos. 

Hair: (+)male pattern baldness

Nails:  no clubbing, capillary refill <2 seconds in upper and lower extremities. 

Head:   normocephalic, atraumatic

Ear: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears.

Nose: Symmetrical. No masses, lesions, deformities, trauma, discharge. Nares are patent bilaterally.

                  Nasal mucosa pink & well hydrated. No discharge noted. 

Mouth/Oropharynx: Lips appear pink and dry, with no masses, cyanosis, or ulcers. Mucosa pink and moist. No lesions or masses.                   No leukoplakia. Palate pink, moist, intact with no lesions, masses, or scars. 

                  No gingival hyperplasia or recession. +Poor dentition.

                  Tongue is midline. No masses or lesions. 

                  Uvula is midline and rises symmetrically with phonation. No edema or lesions.

                  Oropharynx is pink and moist. Tonsils are symmetric and without hypertrophy. No swelling, erythema, exudates,                             masses/lesions, foreign bodies. 

Neck: Full ROM. Supple. Non-tender to palpation. No JVD. Trachea is midline. No masses or lesions. No scars. Lymph nodes                        non-palpable bilaterally. No stridor. 2+ carotid pulses bilaterally. No cervical adenopathy noted. Thyroid is non-tender                      with no palpable masses. No thyromegaly. 

Eyes: Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white, conjunctiva pink                            bilaterally. PERRL.
                 Unable to assess EOM due to patient noncompliance. 

Chest/Pulmonary: Chest is symmetrical, without deformities or trauma. Lat to PA diameter is 2:1. Respirations unlabored. No use                   of accessory muscles noted. Chest nontender to palpation throughout. Lungs CTA bilaterally. No wheezes, rhonchi,                       rales, or other adventitious sounds.

Heart: Regular rate and rhythm. Distinct S1 and S2. No murmurs, S3, S4, friction rubs, or splitting of S2 appreciated. Carotid                          pulses are 2+ bilaterally without bruits.

                  DP PT pulses intact to both lower extremities, slightly decreased on the left. 

Abdomen: Nondistended.  No striae or pulsations noted. Normoactive bowel sounds. Tympanic throughout. Abdomen is soft. No                     tenderness to palpation. No rebound or guarding. No hepatosplenomegaly. No hernia present. 

Mental Status Exam: Appearance and behavior – patient alert, grimacing in pain, appropriate facial expression and manner.                           Clothing is dirty. 

                  Speech and language – follows 2 stage commands. Speech is of appropriate quantity, rate, volume, flow, and                                articulation. 

                  Patient seems agitated. Difficult with following direction. No SI/HI. Oriented to name, date, time, location.

Neurologic: 

Cranial Nerves –See “Eyes” for CN II assessment. No ptosis. Symmetric and fluid facial movements. No difficulty with BMP speech sounds.

Soft palate rises and uvula remains midline. No hoarseness or nasal quality in voice. No facial droop. No difficulty with LTND speech sounds. 

Peripheral Neuro –

Motor/Cerebellar: Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Gait not assessed. 

Meningeal Signs: No nuchal rigidity noted. 

 

Musculoskeletal: Left lower extremity: Left calf region is wider in diameter compared to the right. Erythema distributed along the posterior calf region from below the knee to above the ankle. Area of fluctuance to the mid, medial calf, about 10-in in diameter. Region is hot to touch, very tender on palpation, and with pitting edema. Crepitus noted with palpation as well. 

                  Right lower extremity and bilateral upper extremities: No soft tissue swelling / erythema / ecchymosis / atrophy / or                        deformities. Non-tender to palpation / no crepitus noted throughout. FROM.  No evidence of spinal deformities.   

 

INITIAL LABS: CBC:    WBC = 15.47        Hgb 13.2          Plt 287

                         BMP: Glucose 97 Na 137 Cl 95 BUN 27 Creat 1.73

IMAGING: XR Left Tibia Fibula: “Air in the gastrocnemius muscle – suggestive of an abscess.”

 

Differential Diagnoses: 

• Necrotizing fasciitis/myositis
• Cellulitis
• Abscess
• DVT
• Pyoderma gangrenosum
• Rash

 

Assessment:  60 y/o male presenting with 10 days of worsening left calf pain, now 10/10 severity, which began a few days after injection of heroin. Left calf region is erythematous, hot to touch, edematous, and extremely tender to light palpation with notable crepitus. XR revealed gas in the gastrocnemius muscle. Concern for necrotizing fasciitis. 

 

Plan: 

Obtain blood cultures x2, then immediately start IV broad spectrum antibiotics (he was given zosyn and clindamycin).

Patient will be taken to the OR immediately for emergency exploration of the left lower extremity and with possible debridement.

 

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RELATED JOURNAL ARTICLE:

Karnuta, J., Featherall, J., Lawrenz, J., Gordon, J., Golubovsky, J., Thomas, J., Ramanathan, D., Simpfendorfer, C., Nystrom, L. M., Babic, M., & Mesko, N. W. (2020). What Demographic and Clinical Factors Are Associated with In-hospital Mortality in Patients with Necrotizing Fasciitis?. Clinical orthopaedics and related research, 478(8), 1770–1779. https://doi.org/10.1097/CORR.0000000000001187

This was a level III level of evidence retrospective study that analyzed the demographic and clinical factors associated with in-hospital mortality in patients with necrotizing fasciitis within a 10 year period. It included 115 patients, of whom only 15% died during their hospitalization. Demographic features associated with mortality in this population were older age, CAD, CKD, and transfer from an outside hospital. Clinical characteristics identified to be associated with mortality were positive initial blood cultures, lactic acidosis, and multiple organ dysfunction syndrome. Their results suggested that the LRINEC score was a poor predictor of mortality.

PDF: Nec Fasc Mortality